TAVI had a non-significantly lower incidence of death or disabling stroke compared to SAVR (2.8% vs. 5.1%; logRR 0.02; 95% CI 0.00-0.04; p=0.11) in young, low-risk patients with severe AS.
Meta-Analysis (n=4,252)
Does TAVI reduce the composite of death or disabling stroke compared to SAVR in young, low-risk patients with severe symptomatic aortic stenosis?
TAVI is non-inferior to SAVR in short-term outcomes for young, low-risk patients with severe aortic stenosis, offering lower rates of disabling stroke and bleeding but higher rates of pacemaker implantation and paravalvular leak.
Effect estimate: logRR 0.02 (95% CI 0.00-0.04)
Absolute Event Rate: 2.8% vs 5.1%
p-value: p=0.11
Abstract Introduction Severe aortic stenosis (AS) was traditionally managed with surgical aortic valve replacement (SAVR). Transcatheter aortic valve implantation (TAVI) emerged as a less invasive alternative, originally for high-risk patients. Its use expanded to intermediate- and low-risk older patients based on promising results. This meta-analysis evaluates TAVI's outcomes in younger, low-risk patients, where SAVR is currently the gold standard. Methods Following PRISMA guidelines, we systematically searched randomized controlled trials (RCTs) comparing TAVI with SAVR in young (i.e. mean age 75 years) low-risk patients (i.e. STS score 4%) with severe symptomatic AS. The primary endpoint was a composite of death or disabling stroke. Secondary endpoints included all-cause mortality, disabling stroke, atrial fibrillation (AF), permanent pacemaker implantation (PPI), bleeding, functional class (NYHA), and quality of life (KCCQ score) improvements and prosthesis-related outcomes. Results Four RCTs were included with 4252 patients (2125 TAVI and 2127 SAVR). At a mean follow-up of 16±5 months, TAVI had a non-significantly lower incidence of death or disabling stroke (2.8% vs. 5.1% logRR 0.02 0.00-0.04 p=0.11), and all-cause mortality (2.1% vs. 3.7%, logRR 0.01 0.00-0.03 p=0.15). Disabling stroke was significantly lower in the TAVI group (0.9 vs. 2.1 logRR 0.010.00-0.02 p0.01). Hospital readmission (7.1% vs. 9.5% logRR 0.03 0.01-0.04 p0.01), and bleeding rates (4.7% vs. 16%, logRR 0.14 0.07-0.20 p0.01) were significantly lower in the TAVI group. On the other hand, TAVI had a higher PPI rate (14% vs. 6%, logRR -0.08 -0.13; -0.02, p0,01) and significant paravalvular leak (2,5% vs. 0,5% logRR -0,02 95%CI -0,04; -0,00 p0,01 I2=77%). There were no statistically significant differences in the other prosthesis-related outcomes between both groups. Faster symptomatic and quality of life improvements were sustained in the TAVI group. Conclusion TAVI is a viable option for young low-risk patients with severe AS, being non-inferior to SAVR in all short-term outcomes. The benefits of TAVI include a lower risk of disabling strokes, reduced rates of readmission and bleeding, and faster-sustained improvements in symptoms and quality of life. The higher PPI and paravalvular leak rates in the TAVI group highlight the need for careful patient selection.
Almeida et al. (Sat,) conducted a meta-analysis in Severe symptomatic aortic stenosis (n=4,252). Transcatheter aortic valve implantation (TAVI) vs. Surgical aortic valve replacement (SAVR) was evaluated on Composite of death or disabling stroke (logRR 0.02, 95% CI 0.00-0.04, p=0.11). TAVI had a non-significantly lower incidence of death or disabling stroke compared to SAVR (2.8% vs. 5.1%; logRR 0.02; 95% CI 0.00-0.04; p=0.11) in young, low-risk patients with severe AS.